Strategies to Minimise the Consequences of Trauma to the Teeth

Paul V Abbott1, Jacqueline Castro Salgado2

Winthrop Professor of Clinical Dentistry - Program Director (Endodontics), School of Dentistry, The Unviersity of Western
1

Australia - 17 Monash Avenue NEDLANDS WA 6009, Australia. 2Associate Professor - School of Dentistry, The University of
Western Australia, Australia.

Abstract
Trauma to the mouth involves not only the teeth but also the dental pulp, the periodontal ligament, bone, gingiva and other associated
structures. There are many different types of injuries with varying severity in each case and often more than one injury to a tooth
at the same time. Hence, there are many different potential responses of the pulp, peri-radicular and soft tissues following trauma.
The responses of the different tissues are inter-related and dependent on each other, which results in many potential consequences
of trauma to the teeth. It is imperative that dentists have a thorough understanding of the possible tissue responses so appropriate
treatment can be provided to minimise the consequences of trauma. The five main strategies to reduce these consequences are to:
1) perform a thorough examination and accurate diagnosis to identify all injuries and to assess the likely healing responses; 2)
reposition and stabilise the teeth and bones to provide optimum conditions for healing; 3) carefully manage soft tissues to help
healing; 4) commence root canal treatment immediately in specific situations to prevent external inflammatory resorption; and
5) follow-up and review all traumatised teeth to identify and manage any adverse consequences as soon as they occur in order to
minimise their effects on the patient.

Introduction occur, compared to fully developed teeth [8], or it may be

Trauma to the teeth is a relatively common occurrence [1].
Some studies suggest that every second person will experience
some form of dental trauma by the age of 14 years with
approximately 30% of the injuries involving deciduous teeth
and 22% involving permanent teeth [1-3]. Fortunately, the most
common injuries are relatively minor, being uncomplicated
crown fractures, concussion and subluxation [4,5]. This review
will only discuss trauma to the permanent dentition.
A patient who has suffered trauma to the teeth may present
as an emergency and in many cases the accident occurs out
of normal office hours for most dentists [4,6,7]. Hence, the
patients may present to a hospital or other medical centre where
a dentist may not be readily available to provide appropriate
care. In addition, and partly as a result of the above, most
dentists do not regularly provide emergency treatment for
injuries to the teeth and this may lead to uncertainties about
what is the most appropriate treatment for each injury. All of
these factors can lead to delays in treatment or inappropriate
treatment, both of which may have negative consequences on
the prognosis of the injured teeth. The long-term prognosis
of teeth that have been damaged is very dependent on the
emergency management and how quickly this is provided.
Upper central incisors are the most commonly injured
teeth and boys tend to have trauma twice as often as girls [1-
5]. The peak age ranges for dental injuries are between 2-4
years and 8-10 years [1,2]. The significance of these ages is
important to note. In the 2-4 year age group, the injury occurs
to the deciduous teeth but the underlying permanent teeth are
developing and their development may be affected by some
injuries to the deciduous teeth (e.g. intrusion, avulsion, etc).
Typical developmental defects include enamel defects such as
hypoplasia and root dilacerations. In the 8-10 year age group,
the permanent incisors are not fully developed, especially
in boys, where there may be short roots, thin dentine walls
and open apices. The incomplete root development may be
advantageous in that pulp revascularisation is more likely to
a disadvantage such as when pulp necrosis and infection of
the root canal system occurs. Such teeth will have a poorer
prognosis due to the lack of dentine in the tooth root and they
will require extensive or complicated endodontic procedures [9].
As outlined by Lauridsen et al. [10], there are six types of
luxation injuries plus nine types of fractures that can occur
to the teeth and each is a unique injury to the soft and hard
tissues. There are often concurrent injuries - such as a luxation
and a fracture – with 54 possible combinations and thus 54
different scenarios for healing. In addition, there are 19 cellular
systems in the dental organ and these can all have different
healing responses and potentials [10]. Thus, the consequences
of injuries to the teeth and their surrounding tissues can range
from very little to very complex.
Some injuries may have no, or only minor, long-term
consequences. As an example, an enamel infraction may not
have any long-term effects on the tooth and may only require
monitoring to ensure that no problems develop such as pulp
necrosis and infection of the root canal system. Similarly, a
tooth with a concussion injury may only require reviews to
monitor it in the long-term. On the other hand, some dental
injuries can have severe long-term consequences that require
complex and continuing management - for example, a tooth
with a complicated crown-root fracture may require root canal
treatment, periodontal surgery, a post-retained core and a full
crown restoration plus long-term reviews and maintenance.
Such a restoration and the root canal filling may also require
replacement at various times throughout the patient’s life.
Another example of an injury with complex and severe
consequences is an avulsed tooth that has been replanted.
Initially such a tooth may show some healing but later may
develop external replacement resorption and ankylosis,
leading to extraction and the need for prosthesis such as an
osseointegrated implant and a crown restoration, which will
then require long-term reviews and maintenance.

Corresponding author: Paul V Abbott, Winthrop Professor of Clinical Dentistry, School of Dentistry, 17 Monash Avenue NEDLANDS
WA- 6009, Australia, Tel: +61 8 9346 7636; Fax: +61 8 9346 7666; e-mail: paul.v.abbott@uwa.edu.au
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Tissue Responses to Trauma Table 1. Possible responses of the pulp and root canal system fol-
The dental pulp and the peri-radicular tissues can both be lowing trauma to a tooth.
affected by trauma to the teeth [10]. The responses of these Responses of the Dental Pulp and Root Canal System to
tissues will determine the treatment required and the outcome Trauma
of the teeth. Hence, it is important to consider the various Favourable Responses
responses that can occur in these tissues. • Recovery and return to normal
Responses can be favourable or unfavourable in nature. • Pulp fibrosis
• Pulp canal calcification
Favourable responses do not generally require any treatment
Unfavourable Responses
and therefore the management required is simply regular
reviews to monitor the teeth over time and ensure there are no • Pulp necrosis
• Infection of the root canal system
changes in the state of the tooth or its associated tissues that • Internal root resorption
require treatment. On the other hand, unfavourable responses - Surface, Inflammatory and/or Replacement
will require some form of treatment, depending on the actual • Combinations of the above
response of the tissue. Therefore it is essential to understand - Simultaneously and/or Sequentially over time
the nature of each possible response and its consequences, as
well as how to manage them. Table 2. Possible responses of the peri-radicular tissues following
Tables 1-3 summarise the possible responses of the pulp, trauma to a tooth.
the root canal system, the peri-radicular tissues and the soft Responses of the Peri-radicular Tissues to Trauma
tissues following trauma to a tooth. It is important to note that Favourable Responses
each possible response should not be considered individually • Recovery and return to normal
or as a final, long-term response to the injury since two or • Fibrous healing
• Transient apical breakdown
more responses may occur simultaneously or sequentially
Unfavourable Responses
over time. For example, a pulp may initially recover following
• Cessation of root development
an uncomplicated crown fracture but then it may subsequently • Disturbances to root development
become necrotic and infected if bacteria are able to enter • Bone resorption
the tooth/pulp system (such as when the restoration breaks - Crestal, Apical and/or Lateral
down). Another example is an avulsed tooth that develops • External root resorption
both external inflammatory and replacement resorption - Surface, Inflammatory, Replacement and/or Invasive
simultaneously and then subsequently ankylosis. Furthermore, • Ankylosis
- With or Without Root Resorption
the pulp response cannot be isolated from the peri-radicular or
• Combinations of the above
soft tissue responses. Although they are separate entities with - Simultaneously and/or Sequentially over time
different responses to the injury, a response of one tissue may
affect the response of another tissue. For example, if the root Table 3. Possible responses of the soft tissues following trauma to
canal system is infected and there has been extensive damage a tooth.
to the root surface and/or external surface resorption, then Responses of the Soft Tissues to Trauma
external inflammatory resorption is likely to occur. Hence, Favourable Responses
the entire healing scenario is potentially very complex [10]. • Recovery and return to normal
• Fibrous healing (scar)
Factors Affecting the Responses to Trauma Unfavourable Responses
Table 4 lists the mechanical and biological factors that can • Loss of attachment
affect the responses of tissues following trauma to the teeth. • Gingival recession
The mechanical factors will indirectly affect the responses to • Combinations of the above
- Simultaneously and/or Sequentially over time
trauma since they determine the type of injury and its severity
whereas the biological factors have a more direct effect on the
Table 4. Mechanical and biological factors that can affect the
tissue responses [1]. responses of tissues following trauma to a tooth.
It is essential that clinicians obtain a detailed history from
Mechanical Factors Biological Factors
the patient (or parent of a child patient) regarding how the
• Direct or Indirect trauma • Stage of root development
injury occurred [11,12]. This will alert the clinician to the
• Energy of impact • Extent of pulp involvement
possible injuries that may be present which will facilitate the - includes Mass and Velocity • Degree of displacement of the
examination procedure. This also requires that the clinician • Resiliency of the impacting tooth
must have a thorough understanding of the mechanical factors object • Concurrent injuries to the
and how they lead to different injuries. • Shape of the impacting object same tooth
The absence, or the presence and extent, of the biological • Direction of the impacting force
factors should be determined during the initial examination
following the injury. Radiographs are an essential part of the tissues. In particular, radiographs will show the stage of
examination [11-13] since they reveal injuries that are not root development, the degree of displacement (if any) of the
clinically evident (for example, a horizontal root fracture) tooth, the extent of pulp involvement and whether there are
and they also help to determine whether the biological factors concurrent injuries on the same tooth. In order to fully assess
will play a role in the recovery of the tooth and its associated all injuries, multiple radiographic views are essential [13].

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The biological factors particularly influence the ability of
the pulp to recover following treatment. If the root is not fully
developed, then pulp revascularisation is more likely to occur
[14] and root development can proceed. This will improve the
long-term prognosis of the tooth as more dentine is produced
by the pulp resulting in a “stronger” tooth that is less likely
to fracture [15], particularly if traumatised again. Hence, an
incompletely developed tooth should be managed with the
aim of preserving the pulp.
The degree of displacement is a major factor affecting both
the pulp [8,14] and the periodontal ligament (PDL) healing
[8,16]. Teeth with no or little displacement (luxation) have
a far better prognosis as there is no or little reduction of the
pulp’s blood supply and no or little damage to the cementum
and the PDL. Hence, concussion or subluxation injuries have
the most favourable prognosis, followed by extrusion, lateral
luxation, intrusion and avulsion [8,14,16].
The extent of involvement of the pulp is a factor but not to
the extent that many clinicians believe. Cvek has shown that
even large pulp exposures and pulps exposed for long periods
of time can recover if adequately treated such as with a partial
pulpotomy [17,18]. However, it may not always be possible
to do a partial pulpotomy as teeth with larger pulp exposures
associated with extensive crown or crown-root fractures may
require more radical treatment such as pulp removal and root
canal treatment to enable the tooth to be restored adequately.
Concurrent injuries to the same tooth imply that more tissues
will be involved than if there is only one injury. It is relatively
common for teeth to have concurrent injuries – such as a crown
fracture and a luxation injury at the same time [19,20]. In these
cases, the pulp may be compromised because of the crown
fracture and possible bacterial contamination at the critical
time when the pulp’s blood supply is either reduced or severed
completely by the luxation injury, resulting in a higher chance
of pulp necrosis and infection of the root canal system.
Strategies to Reduce the Consequences of
Trauma to the Teeth
As outlined above, there are many potential consequences
of trauma to the teeth. The most serious and complicated of
these are pulp necrosis and infection of the root canal system,
external inflammatory root resorption, external replacement
root resorption, ankylosis, bone resorption, loss of attachment
and gingival recession. Many of these are inter-related – such
as infection of the root canal system, external inflammatory
resorption and bone loss (and possibly attachment loss
and gingival recession) but they can be largely prevented
by various treatment procedures. However, some of these
consequences of trauma cannot be prevented - such as external
replacement resorption and ankylosis - and they occur because
of the damage induced during the accident. The remainder of
this paper will concentrate on outlining strategies that can be
used to prevent or reduce the consequences of trauma to the
permanent teeth, and it will not discuss the other problems
that may occur. Five key strategies will be discussed in detail
– examination and diagnosis, repositioning and stabilisation
of the teeth and bones, soft tissue management, immediate
root canal treatment in specific situations to prevent external
inflammatory resorption, and follow-up of all traumatised
231
teeth to identify and manage any adverse consequences as
soon as possible.
Strategy No. 1 - Examination and diagnosis
The first strategy to help reduce the consequences of trauma
to the teeth is to fully assess the injuries that are present. This
requires a thorough history as well as a complete clinical and
radiographic examination [11-13]. The examination should
also include tests such as pulp sensibility tests, percussion,
palpation, mobility, periodontal probing, etc.
Radiographs are essential to reveal all injuries as well as
other important factors affecting healing (see above). The
radiographic examination should consist of at least three
periapical radiographs and an occlusal radiograph of the
arch that has suffered the obvious trauma, plus radiographs
of the opposing arch as there may be injuries that are not
immediately obvious [11-13]. Other imaging techniques may
also be of value although they may not always be readily
available or may not be required immediately – such as CT
scans, cone beam CT’s etc.
Pulp sensibility testing is essential [11-13] and there
is no excuse not to do these simple tests at the time of the
initial presentation after trauma. Some clinicians have
argued in the past that such tests are unreliable immediately
after trauma since the pulp is “in shock” and will not give
reliable responses. However, whilst this may be possible,
there is no scientific evidence for this assumption. In contrast,
there is evidence that indicates the immediate responses to
pulp sensibility tests are good indicators of the long-term
prognosis of the pulp [11-13] – for example, very few teeth
that responded to pulp sensibility tests immediately following
concurrent concussion and crown fracture injuries developed
pulp necrosis over time, whereas about 50% of teeth that did
not respond immediately after these same injuries developed
pulp necrosis and infection of the root canal system within six
months [21].
It is important to understand that the results of pulp tests
performed immediately after trauma should not be used to
diagnose pulp necrosis or to indicate immediate root canal
treatment since many pulps may recover – as in the above
example of concurrent concussion and crown fracture
injuries. The immediate pulp test results may also indicate
that a tooth has been traumatised when there are no other
physical signs of injury. Hence, immediate pulp sensibility
testing is essential to provide baseline data for comparison
with subsequent tests and to alert clinicians of the possibility
of pulp necrosis occurring later [11-13].
A thorough history and examination will lead to a thorough
and accurate diagnosis of all injuries present. It is essential to
diagnose each injury and each tissue involved - that is, the
teeth, bone and soft tissues as well as the state of the pulp and
peri-radicular tissues. A thorough diagnosis will then allow
all injuries to be effectively managed. An essential part of the
examination and diagnostic process is to also record all the
details obtained from the history, the clinical examination, the
various tests performed, the radiographic examination and all
of the final diagnoses.
Strategy No. 2 - Repositioning and stabilisation of the
teeth and bones
All tissues that have been displaced or fractured should be
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Figure 1. Rubber dam cuff technique used during the emergency management of a trauma case with an uncomplicated crown fracture of the 11,
a complicated crown-root fracture of the 21, and lateral luxation of the 22.
A) Rubber dam immediately after placement - whilst there is some gingivae showing on the palatal and a gap between the dam and the palate,
this set-up provides excellent conditions to manage the patient and the multiple injuries in this case.
B) Following repositioning of 22, pulp removal from 21, temporary composite restorations and rigid splinting of the teeth with wire and
composite resin – all of which were done under rubber dam isolation.

Figure 2. A) Schematic diagram of a simple splint. The splinting material is placed away from the gingivae and the interproximal tooth surfaces
are not covered by any splinting material. If a flexible splint is required, then use composite resin (shaded pink) to attach nylon fishing line
(coloured red) to the labial surface of the teeth. This splint could be made rigid by substituting the nylon fishing line with stainless steel wire.
B) The splint can also be made more rigid if desired by extending the composite resin further towards the mesial and distal edges of the labial
tooth surfaces to cover more of the fishing line or wire.
C) An example of a flexible splint with nylon fishing line and composite to stabilise the two central incisors that had been avulsed and replanted.
(Note: clinical examples of rigid splints with wire and composite are shown in Figures 1 and 3).

repositioned and stabilised as soon as possible to aid healing.
If they are not returned to their normal positions, then healing
will be impaired and may lead to fibrous/scar tissue formation,
non-union of bone fractures and other complications.
The repositioning, replantation and stabilisation
procedures should all be performed with appropriate general or
local anaesthesia and under rubber dam isolation. Anaesthesia
is required to ensure the patient is comfortable with no pain
during the various procedures to reposition the teeth, bones
and soft tissues, as well as during stabilisation and suturing
(see below). Good pain control during treatment can also help
to reduce the immediate post-operative discomfort.
Rubber dam isolation can be easily achieved using a “cuff
technique” (Figure 1) across the entire anterior portion of the
arch that has been traumatised (for example, from canine to
canine, or from 1st premolar to 1st premolar) with clamps
placed on teeth that were not affected by the trauma. The
use of rubber dam has numerous advantages which include
helping with overall patient management, protection of the
airway and oesophagus, isolation to avoid unnecessary
saliva and bacterial contamination of the affected teeth, ease
of handling the displaced teeth and any loose fragments,
improved handling and performance of the various materials
used as well as improved visibility and access. Patients can
also be more efficiently managed when rubber dam has been
placed. In some cases, pulp treatment may be required (for
example, pulpotomy, root canal treatment, etc) and rubber
dam isolation is required for these procedures – hence, if the
rubber dam is placed prior to repositioning the teeth, then all
required emergency treatment can be readily performed.

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Figure 3. A) An example of poor soft tissue management at the time of replantation of the lateral incisor following avulsion. No sutures were
used to stabilise the gingivae, resulting in gingival recession, loss of attachment and loss of bone.
B) In this different case, the two central incisors had been intruded such that the crowns were not visible, resulting in laceration of the gingivae
in the midline. The laceration was sutured after the teeth were repositioned and stabilised with a rigid splint using wire and composite resin.
C) A five-year follow-up of the case in B) showing excellent soft tissue repair with a normal interdental papilla between the two central incisors.

Displaced teeth: Most teeth that have been displaced are
relatively simple to reposition. They should then be stabilised
by using a splint. Simple splints are preferred as they are easy
to place, easy to remove, cheap, do not interfere with other
treatment (such as suturing, root canal treatment, etc) and
the patient is able to clean around them. Splints are usually
applied to the labial surface of the injured tooth/teeth and
one or two adjacent teeth on each side of the injured tooth/
teeth to provide anchorage. Splints can be quickly made using
composite resin and nylon fishing line (Figure 2) or stainless
steel wire (Figures 1 and 3B). Other materials can also be
used but they may not be as readily available, plus they may
be more complicated to use and more expensive.
The material chosen for a splint depends on the type of
splint required – that is, whether the splint needs to be rigid
or flexible. A rigid splint is one that allows no, or minimal,
movement of the teeth whereas a flexible splint allows normal
physiological movement. Flexible splints are preferred for
most luxation injuries since they allow “functional healing”
of the PDL which reduces the chances of ankylosis and
subsequent replacement resorption [22]. However, if there
has been a root fracture or a fracture of the alveolar bone, then
a more rigid splint is required in order to hold the fractured
hard tissues together while healing [23], especially when the
fracture is located in the coronal third of the root [24]. Rigid
splints can be simply constructed using stainless steel wire
on the labial while a flexible splint can be made with nylon
fishing line (Figures 1-3). The rigidity of the splint can also
be increased by extending the composite resin further across
the labial surfaces of the teeth to cover more of the nylon
fishing line or the wire (Figure 2B). The main purposes of
a flexible splint are to hold the tooth in position while initial
PDL healing occurs and to avoid the possibility of further
displacement, inhalation or swallowing of the tooth.
Lateral luxation injuries typically result in the coronal
portion of the tooth being displaced in a palatal direction
with the apical part of the root being displaced labially [1,12].
There is also a fracture of the labial wall of the alveolar socket
and this typically occurs at about the level of the junction
of the apical third and middle third of the tooth root [1,25].
This creates a “ledge” of bone that then traps or locks the
root apex labially. Hence these teeth need to be repositioned
by first pushing downwards with a finger on the root apex to
disengage it from the bone ledge, and then pushing the coronal
part of the tooth towards the labial direction [25]. Typically,
233
the dentist will feel the tooth “click” back into place. Since
there is also a bone fracture associated with lateral luxation,
this injury requires a rigid splint (Figure 1) for about six
weeks in adults or about four weeks in children.
Extruded teeth are simple to reposition as they usually
just need to be gently pushed back into the socket by using
a finger applied to the incisal edge [26]. They should then
be stabilised for 7-10 days with a flexible splint since there
are usually no associated bone fractures. Some teeth may be
difficult to reposition fully when a blood clot has formed in
the apical part of the socket – hence, the sooner these teeth are
repositioned, the easier it will be. If they cannot be fully seated,
then subsequent orthodontic treatment may be required.
Intruded teeth should ideally be repositioned immediately
although there is some debate and controversy about the
management of this type of injury. Another recommendation
is to wait and see if the tooth re-erupts by itself over
the following few weeks. If this does not occur, then
orthodontically extrude the tooth. Whilst this latter approach
has been shown to be feasible, especially with incompletely
developed teeth [27], there are some potential problems and
disadvantages associated with it. Firstly, leaving the tooth in
an intruded position is leaving the PDL and surrounding bone
in an unfavourable situation as the pressure on these tissues
may lead to necrosis, which in turn may lead to ankylosis
and replacement resorption. Secondly, pulp necrosis occurs
in virtually all fully developed teeth following intrusion as a
result of crushing of the neurovascular bundle in the periapical
region [19,20]. This in turn can lead to infection of the root
canal system, especially if there is also a crown fracture or
infractions that can allow bacteria to enter the tooth/pulp
system. Then, the ideal conditions are established for external
inflammatory root resorption to occur. Hence, ideally,
immediate root canal treatment should be commenced in these
teeth (see below) in order to prevent inflammatory resorption.
This requires access to the root canal system which would
normally be gained via a palatal access cavity cut with a high
speed handpiece. This would be very difficult to perform in
teeth that are extensively intruded and therefore repositioning
and stabilisation with a splint would make this procedure far
easier to perform. Similarly, pulp necrosis is extremely likely
in incompletely developed teeth that are intruded and also have
a crown fracture [19,20]–therefore these teeth should ideally
have root canal treatment commenced immediately in order
to prevent inflammatory resorption. Thirdly, spontaneous
 OHDM - Vol. 13 - No. 2 - June, 2014
eruption is unreliable when the tooth root is fully developed
[28], and finally, if the tooth does not spontaneously re-erupt
and orthodontic treatment becomes necessary, the patient
will be subjected to a surgical procedure in order to attach
orthodontic appliances to the tooth so it can be extruded.
This extra treatment can be avoided simply by immediately
repositioning the tooth as soon as possible after the injury.
Once repositioned, intruded teeth require a rigid splint
(Figure 3B) as it is very likely that there will also be a
fracture of the alveolar bone – this occurs because the tooth is
essentially shaped like a wedge and can easily cause the labial
wall of the socket to expand and fracture as the tooth is forced
into the bone. Intrusion will always cause comminution
(crushing) of the bone. Hence, rigid splinting for 4-6 weeks is
preferred to allow optimum bone repair.
Avulsed teeth will need to be replanted back into the
tooth socket [29]. The socket should first be checked to see
if there is a blood clot present as this may prevent full seating
of the tooth. If a blood clot is present, it can usually be easily
removed with tweezers or a very fine suction tip – in all cases,
be sure to avoid touching the socket wall as this may damage
the PDL that remains on the socket wall. Gentle irrigation of
the socket with saline can also help to remove a blood clot –
if this is being done, then needles should be avoided as they
may damage the PDL. Plastic syringes that include plastic tips
are preferred – such as those used during surgical procedures
for irrigation. Avulsed teeth may or may not have associated
fractures of the alveolar wall. If a fracture is present, a rigid
splint should be used but otherwise a flexible splint (Figure 2)
is recommended for 7-10 days [29].
Fractures: Fractures also require repositioning and
stabilisation of the fractured tissues. Crown fractures can be
managed in a variety of ways using various dental restorative
materials. The choice of material and technique will depend
largely on the position and extent of the fracture. The pulp
must be considered in all cases, even if it is not obviously
exposed. Where no obvious exposure, the dentine should be
covered in order to protect the pulp since the dentinal tubules
provide direct pathways of entry for bacteria to reach the
pulp if left open. This can be achieved with materials such as
glass ionomer cements and composite resins. When the pulp
is exposed, the stage of root development is the main factor
that determines how the pulp should be managed. If the root
is incompletely developed, then a conservative pulp treatment
procedure should be utilised – such as a pulp cap, a partial
pulpotomy, a cervical pulpotomy or a partial pulpectomy.
The partial pulpotomy procedure advocated by Cvek is the
treatment of choice due to the very high rate of favourable
outcomes reported [17,18]. However, the choice of procedure
will depend on the level of the crown fracture – for example, if
the crown has fractured at gingival level, then only a cervical
pulpotomy or a partial pulpectomy will be possible.
Fractures of a tooth root can present in many forms ranging
from a single fracture to multiple fractures, in different parts
of the tooth root (apical third, middle third, coronal third,
sub-osseous, supra-osseous) and in different directions.
In general, teeth with root fractures should be managed by
repositioning the coronal fragment if it has been displaced
and then stabilisation with a rigid splint [23,30,31]. There is
234
some debate about how long these teeth should be splinted
with some studies suggesting that only 3-4 weeks is necessary
[23,31] while others recommend a longer period of 3-4
months to allow more time for hard tissue repair. If conditions
are favourable, root-fractured teeth can repair internally by
forming dentine along the root canal wall across the fracture
line, and by cementum repair on the external surface of the
root and perhaps extending into the fracture line giving the
radiographic appearance of healing with hard tissue [31]. The
dentine formation can only occur if the pulp is healthy and the
odontoblasts adjacent to the fracture are stimulated to produce
reactionary dentine along the root canal wall to cover the
fracture line internally. It is believed that this dentine will be
less likely to form if the coronal fragment is mobile and hence
the longer splinting time is thought to create better conditions
for pulp repair. Such repair is only likely to occur soon after
the trauma and it is extremely unlikely to occur later.
It is very important that the pulp is not removed from teeth
with root fractures as part of the emergency and short-term
management. The pulp recovers in many teeth and may never
need root canal treatment, even in cases where the fracture
is close to the crestal bone level [23,24,30-33]. A number of
studies have been published and summarized by Andreasen et
al. [31] with varying rates of pulp necrosis after root fractures
– ranging from as low as 4% to 55%. If the results of these
studies are combined, a total of 1017 teeth had root fractures
and only 274 (26.9%) developed pulp necrosis. Hence, the
overall prognosis for pulp survival is very good following root
fractures although there are many factors that affect individual
cases. Pulp survival in root-fractured teeth is desirable since
the pulp may produce reactionary dentine, as outlined above,
which will help to stabilise the tooth.
Root canal treatment of root-fractured teeth should only
be considered when there are very definite symptoms and/or
signs of infection of the root canal system and these typically
take some time to manifest. Such symptoms and signs include,
but are not limited to, pain, swelling, increased mobility of
the coronal fragment, a draining sinus, external inflammatory
resorption of the coronal fragment, radiolucency between
the coronal and apical fragments as well as adjacent to the
fracture line, etc. In these cases, root canal treatment is only
required for the coronal fragment – that is, only treat the canal
to the fracture line. Calcium hydroxide can be used to ensure
disinfection of the root canal and to encourage hard tissue
healing at the fracture line (i.e. across the entrance to the
coronal fragment’s root canal). The canal can then be filled
with gutta percha and cement, or with other materials such as
Mineral Trioxide Aggregate (MTA) with various techniques
[24,31,34].
Root fractures in the coronal third of the root benefit from
longer splinting times up to 4 months [24] and these teeth
should also be monitored to assess the pulp response and peri-
radicular healing. However, in some cases of coronal third
root fracture, it may be better to remove the coronal fragment
and then commence root canal treatment immediately. This
only applies to teeth where the fracture occurs just below the
gingival margin but not below the level of the crestal bone, or
where there is communication with the gingival crevice [31].
In these cases, the coronal fragment would have no bone and
 OHDM - Vol. 13 - No. 2 - June, 2014
no effective PDL to support it. These teeth will subsequently
require a root canal filling and a comprehensive restoration
using a post/core and full coverage crown but these can be
provided when convenient rather than immediately. These
teeth may also require orthodontic extrusion to facilitate
their restoration [35]. In addition, periodontal surgery may
be required to expose the margins to allow restoration of the
tooth. Immediate management of complicated crown-root
fractures is similar [36].
As above, bone fractures often occur with luxation injuries
and should be managed in conjunction with the teeth. Bone
fractures can also present as a fracture of the alveolar process
with or without involving the tooth socket [1]. These injuries
should not be confused with luxation injuries of the teeth but
they may appear similar to lateral luxations or intrusions.
However, the main distinguishing finding is that two or more
teeth will move together as a segment rather than moving
as individual teeth when one is tested for mobility [1]. All
involved teeth will also be displaced in the same direction
and to the same extent which is unlikely if they were separate
luxation injuries. Alveolar process fractures are managed
by repositioning the loose segment of bone which can be
achieved by finger manipulation of the teeth to guide the bone
back into position [37,38]. The teeth should be returned to
their normal position in the arch which can be checked by
assessing the occlusion. Once repositioned, a rigid splint can
be placed on the teeth to hold the fractured bone segments
together for optimum healing.
Fractures of the jaw (mandible and/or maxilla) can also
occur when there is trauma to the teeth. These injuries are
complex and will not be discussed in this review. Details
can be obtained from appropriate oral surgery textbooks and
journals. However, it is important to note that the teeth must
not be neglected when there has been a jaw fracture since
the blood supply to the dental pulps may have been affected
by the injury and even by the treatment of the injury [38].
Teeth may also have injuries such as crown fractures, root
fractures, luxation, etc so a thorough examination is required
to identify and then manage these injuries in conjunction with
the jaw fracture. Some teeth may also be involved in that the
jaw fracture may involve the tooth socket. In this situation,
the tooth should ideally be kept in place when the fracture is
stabilised in order to reduce the chances of infection through
an open socket if the tooth is removed. The tooth should
also be carefully monitored for potential problems such as
pulp necrosis and infection of the root canal system, root
resorption, loss of attachment, gingival recession and other
periodontal problems [38].
Strategy No. 3 - Soft tissue management
The third strategy to help reduce the consequences of trauma
to the teeth is to know when soft tissue management is
required. Attachment loss and gingival recession are two
complications that can be largely avoided through good tissue
management (Figure 3A). This requires that the soft tissues are
repositioned back to their normal position and then stabilised
in this position [39]. Stabilisation usually involves the use
of sutures (Figure 3B and 3C) although other techniques or
materials (such as cyanoacrylate) can sometimes be used.
Abrasions and contusions do not require much in the way
235
of treatment. Abrasions should be thoroughly cleaned and
disinfected but these are rare in the mouth. They are more
likely to be on the external facial surface. Intra-oral contusions
are also not common and they only require symptomatic
relief if they are causing discomfort to the patient [39] – in
which case, a non-steroidal anti-inflammatory drug would be
indicated (such as ibuprofen).
Lacerations will require sutures to hold the cut surfaces in
close proximity to each other in order to facilitate healing by
primary intention [39]. Lacerations will often be associated
with injuries where teeth are displaced – such as luxation,
avulsion, alveolar bone fractures, alveolar process fractures,
etc. The lacerated tissues require repositioning as do the teeth
and bones; they then require stabilisation even if the laceration
is only small, or short in length. The simple placement of a
suture can avoid unsightly gingival recession as well as the
subsequent loss of attachment and loss of crestal bone height
(Figure 3). These can all lead to aesthetic problems as well
as eventual loss of the tooth due to loss of PDL and bone
support.
Many lacerations are obvious on examination but others
require some probing or investigation in order to be revealed.
In particular, luxations may be associated with “degloving-
type” injuries of the gingivae on the palatal surface of upper
incisors. In this case, the laceration is effectively occurring
between the gingivae and the underlying bone and gingival
fibres attached to the tooth. The displaced soft tissue may not
be obvious on visual examination as it may be passively lying
over the underlying bone. However, it is readily identified
by periodontal probing and by testing the mobility of the
soft tissue. Once identified as a degloving injury (i.e. a form
of laceration), this tissue must be stabilised with sutures to
ensure optimum positioning and conditions for healing. If
it is not repositioned and stabilised, then loss of attachment,
gingival recession, bone loss, etc. will occur over time.
Lacerations of the lip in patients who also have crown
fractures should be carefully checked to determine whether
any tooth fragments have penetrated the lip. Foreign objects
may also penetrate the lips if the skin has also been lacerated
[39]. In such cases, the lips should be radiographed with a
film or sensor placed between the lip and teeth to check for
tooth fragments and foreign objects. The exposure for such
a radiograph should be 25% of the normal dose for intraoral
radiographs. If any tooth fragments or foreign objects are
present, these must be removed before the lacerations are
sutured [39].
Strategy No. 4 – Immediate root canal treatment to prevent
external inflammatory resorption in specific situations
The fourth strategy to help reduce the consequences of trauma
to the teeth is to know when immediate pulp removal is
required. As mentioned above, one of the complications or
consequences of trauma to the teeth is external inflammatory
root resorption (Figure 4). This type of resorption occurs
when the root canal system has become infected AND where
there has been either mechanical damage to the cementum
during the trauma or loss of cementum through external
surface resorption to the extent that the dentinal tubules have
been exposed [40]. The bacteria in the root canal system can
either move through the tubules and invoke the inflammatory
 OHDM - Vol. 13 - No. 2 - June, 2014
Table 5. The injuries that are likely to result in pulp necrosis and infection of the root canal system, according to the stage of root development
at the time of injury. Immediate root canal treatment following repositioning/replantation and splinting should be considered for teeth with these
injuries in order to prevent the development of external inflammatory root resorption.
Incompletely Developed Teeth
• Intrusion with crown fracture
• Avulsion with crown fracture
response in the PDL or the endotoxins produced by the
bacteria may diffuse through the dentine to cause this. It may
even be both the bacteria and their endotoxins. When there
has been trauma to the PDL – such as a luxation injury – there
will already be an inflammatory response in the PDL (because
of the injury) so the bacteria and /or their endotoxins may
only need to exacerbate this existing inflammation in order
to initiate inflammatory resorption. Once the clastic cells are
activated, the resorptive process will progress through the
tooth root unless appropriate treatment is provided.
Studies have shown that it is possible to arrest external
inflammatory resorption [40-42] and also to prevent it from
occurring [41-46]. Since this type of resorption is dependent
on having an infected root canal system, prevention or arrest
of this resorption can be achieved through root canal treatment
and by applying the same general principles that are used for
such treatment [41-46]. As with all diseases, it is far better for
the patient, and generally far more successful in outcome, to
adopt a preventive approach rather than to wait for the disease
to occur and then have to treat it.
When considering whether external inflammatory
resorption is likely to occur to any particular tooth after
trauma, the two key questions to answer are:
1. How likely is pulp necrosis and infection of the root
canal system?
2. Has the external root surface been damaged or is
external surface resorption likely to occur?
The literature can be used to determine which injuries
are likely to have both of the above occur – these injuries
are summarised in Table 5, according to the stage of root
development at the time of injury. In general, pulp necrosis
and infection are more likely with severe displacement
236
Figure 4. A) Schematic diagram of external inflammatory
resorption showing loss of tooth structure and loss of
adjacent bone in the form of radiolucencies. External
inflammatory resorption can occur on the lateral root
surface or at the apex of the root.
B) Radiograph showing external inflammatory resorption
on the mesial surface (indicated by the arrow) of the root
of the upper right central incisor – this was evident six
months following avulsion and replantation of the tooth.
Fully Developed Teeth
• Avulsion
• Intrusion
• Lateral Luxation with crown fracture
• Extrusion with crown fracture
injuries and these are also the most likely injuries to have
damage to the root surface [19,20]. The presence of a crown
fracture also makes pulp necrosis and infection more likely
[20] because the fracture provides pathways for bacteria to
enter the tooth and pulp system – such pathways could be
a direct pulp exposure (i.e. a complicated crown fracture),
exposed dentine tubules (uncomplicated crown fracture) or
even through cracks when infractions occur.
Root surface damage increases as the degree of
displacement increases – thus, concussion and subluxation
rarely result in inflammatory resorption whereas intruded
and avulsed teeth are very likely to have this resorption [47].
Extrusion and lateral luxation generally have less root surface
damage and therefore less chance of inflammatory resorption
unless there is also a crown fracture, as above. Root surface
damage can also lead to external replacement resorption
which is largely related to damage to the cementum and PDL.
Unfortunately, external replacement resorption cannot be
arrested once it has commenced and therefore it is important
to minimise its occurrence where possible – however, this is
not always possible since the damage usually occurs as part
of the actual injury. External replacement resorption has a
different radiographic appearance (Figure 5) and the tooth
will give a different sound on percussion once this resorption
is well established. Clinicians should be able to distinguish
between external inflammatory and replacement resorption so
appropriate treatment can be provided.
Immediate root canal treatment following repositioning/
replantation and splinting should be considered for teeth
with the injuries listed in Table 5 in order to prevent the
development of external inflammatory root resorption. This
recommendation is based on numerous studies that have
 OHDM - Vol. 13 - No. 2 - June, 2014

Figure 5. A). Schematic diagram of external replacement resorption showing loss of tooth structure and its replacement by bone. B) Radiograph
of an upper right central incisor that had been avulsed, replanted and splinted. The tooth had been out of the mouth and stored dry for three
hours. The dentist performed extra-oral root canal treatment and placed a rigid splint. C) The tooth developed external replacement resorption
which slowly progressed. This radiograph was taken four years after the injury and shows extensive resorption and ankylosis.

investigated this type of resorption and the effects of root canal
treatment with various intracanal medicaments. Some studies
have also investigated the effects of systemic antibiotics on
this type of resorption. These studies are summarised below.
Hammarström et al. [42] showed that immediate systemic
use of antibiotics (penicillin and streptomycin) prevented
external inflammatory resorption in a monkey study where
teeth were avulsed, infected and replanted. However, if
the antibiotics were given three weeks after the procedure,
they had no effect as inflammatory resorption was already
established and it continued despite the antibiotics. They also
tested the intra-canal use of the same antibiotics and they
reported that placing them immediately after replantation
prevented inflammatory resorption. If they were placed in
the root canal after three weeks, then they almost completely
eliminated the resorption [42].
Sae-Lim et al. [44] used an “inflammatory resorption”
model in dogs to compare the effects of systemic tetracycline,
amoxicillin and a control without antibiotics. They reported
that the tetracycline group had significantly less inflammatory
resorption (33% of the root surface) than the control group
(72%) but only slightly better than the amoxicillin group
(43%) which was not significantly different to the control
group. They concluded that since tetracycline has been
shown to have anti-resorptive properties as they inhibit
clastic cells [48] in addition to its anti-bacterial properties,
it could be considered as an alternative to amoxicillin after
avulsion injuries to prevent inflammatory resorption [44].
Tetracyclines have other properties which make them
advantageous, especially when used within the tooth as
intracanal medicaments as outlined below. These properties
include their substantivity [49] and their bacteriostatic nature
[50]. The latter is an advantage since, in the absence of
bacterial cell lysis, antigenic by-products such as endotoxins
are not released [50]. Tetracyclines also inhibit mammalian
collagenases and therefore they help to prevent tissue
breakdown [48].
237
In another study using a “replacement resorption” model
in dogs and the same medication groups, Sae-Lim et al.
[51] showed that there were significantly more teeth in the
systemic tetracycline group with more than 50% of the root
surface showing completely healed sites than in the systemic
amoxicillin and control groups. In addition, there was more
healing overall in the tetracycline group (35%) than in the
amoxicillin (10.9%) and control groups (11.2%). Hence, the
systemic use of tetracycline may also help to prevent external
replacement resorption to a limited extent [51].
Corticosteroids have been investigated for their effects on
inflammatory resorption because they are potent inhibitors
of inflammation and they have a direct anti-resorptive action
thorough their ability to inhibit clastic cells. Sae-Lim et al.
[52] showed in their dog “replacement resorption” model
that 85% of the root surface had complete healing when
dexamethasone was applied topically before replantation
of the extracted teeth whereas the systemic dexamethasone
group had 67% of the root surfaces with healing. This latter
group was similar to the control group (topical tissue culture
medium) which had 69% of the root surface with healing.
Pierce and Lindskog [43] investigated the effects on
inflammatory resorption of a commercially available
corticosteroid/tetracycline compound known as Ledermix
paste (Haupt Pharma GmbH, Wolfratshausen, Germany). In
this study, they extracted monkey incisors, left them dry on
the bench for an hour and then replanted them. The canals
were also infected to create conditions to induce inflammatory
resorption. One group of teeth had Ledermix paste placed in
the root canals after three weeks and the other group were
left empty. The Ledermix group showed no inflammatory
resorption and no resorption in the PDL. In stark contrast,
the other group had 89.3% of the root surface undergoing
inflammatory resorption and another 8% of the root surface
associated with inflammation in the PDL. The Ledermix group
had 25.1% of the root surfaces with external surface resorption
but this had not progressed to inflammatory resorption. There
 OHDM - Vol. 13 - No. 2 - June, 2014
was also 68% of the root with replacement resorption and/or
ankylosis but this was a direct effect of the teeth being left dry
on the bench for one hour prior to replantation since this would
have resulted in necrosis of most of the PDL cells on the tooth
root. Hence, this study showed that delayed placement of
Ledermix paste prevented inflammatory resorption but it had
no effect on replacement resorption [43]. Pierce et al. [53] then
tested whether the anti-resorptive activity was due to the full
paste (corticosteroid plus tetracycline) or just the tetracycline
component (demeclocycline). Exposure of rat dentinoclasts to
the demeclocycline was less effective than the entire paste,
suggesting that the corticosteroid component was the most
active anti-resorptive component. This is consistent with
work by Suda et al. [54] who reported significant inhibition of
osteoclasts when exposed to hydrocortisone.
The effect of corticosteroids has been subsequently
confirmed by Chen et al. [46] in a dog study where they
tested the immediate intracanal placement of Ledermix
paste, triamcinolone alone, and demeclocycline alone. The
control group had root canal fillings with gutta percha and
cement. The teeth treated with Ledermix paste, triamcinolone
and demeclocycline had statistically significantly more
favourable healing (75.8%; 69.8%; 52.4%, respectively) and
more remaining root structure (5.59; 5.48; 5.09 respectively
on a scale of 1-6) than the positive control group (0; 1.15).
There was no statistically significant difference between the
Ledermix group and the triamcinolone group but there was
a difference between these groups and the demeclocycline
group. These results clearly indicate that the corticosteroid
was the major anti-resorptive agent in Ledermix paste [46].
However, in this study, the canals were not infected so the
true value of the tetracycline component is difficult to assess.
It is expected that if the canals were infected, then the role of
the antibiotic would be more important than in noninfected
teeth since the antibiotic would inhibit any bacteria that enter
the root canal system as well as potentially preventing any
bacteria from entering the canal.
The timing of placement of the Ledermix paste is critical
[45]. Inflammation begins as soon as the trauma has occurred to
the tooth and therefore the sooner the anti-inflammatory agent
is applied, the sooner it can begin to reduce this inflammatory
reaction. In addition, if bacteria are prevented from entering
the root canal system, then external inflammatory resorption
is not likely to occur. Hence, if pulp necrosis is expected,
then the immediate removal of the pulp and the placement
of an appropriate medicament in the canal would seem
advantageous and this has been shown to be the case by
Bryson et al. [45]. In that study, the immediate placement of
Ledermix paste was compared to the immediate placement
of calcium hydroxide. The Ledermix group had significantly
less resorption, significantly more healing and significantly
more residual root mass than the calcium hydroxide group.
Calcium hydroxide has some useful properties in that
it is a powerful anti-bacterial agent [9] but it has no direct
anti-inflammatory action. Calcium hydroxide is a relatively
toxic material which induces necrosis of cells that come into
contact with it [55-57]. Hence, it can induce necrosis of both
the resorbing cells and the reparative cells. This action on the
reparative cells favours ankylosis and replacement resorption
238
rather than healing of the PDL [55-57]. When placed in a
root canal, calcium hydroxide will release the hydroxyl ion
which diffuses through the dentinal tubules and cementum to
reach the PDL [58]. If the cementum has been removed by
the trauma or by surface resorption, then the diffusion of the
hydroxyl ion will be faster and greater. The pH in the outer
dentine can reach levels of approximately 8.0-9.5 [58] which
is higher than the level at which attachment and growth of
human PDL fibroblasts decreases (i.e. 7.8) [57]. Hence,
calcium hydroxide can also affect PDL healing in this way
and again the response favours ankylosis and replacement
resorption [57].
When Ledermix paste is placed in the root canal of
teeth, it releases the active components (triamcinolone and
demeclocycline) [59]. These active components then diffuse
through the dentine as well as through any lateral canals and
the apical foramen to reach the peri-radicular tissues [59]. The
major diffusion pathway is via the dentine tubules [59] and
this diffusion increases if the cementum has been removed
by the trauma or by surface resorption [60]. Hence, there
is ready availability of the active components to the tissues
where they can act to prevent inflammatory resorption. The
tetracycline (antibiotic) works within the dentine tubules
by inhibiting bacterial growth whilst the triamcinolone
(corticosteroid) works within the peri-radicular tissues by
reducing inflammation and inhibiting clastic cells. Ledermix
has been reported to maintain the release and diffusion
process for about six weeks in fully developed teeth and for
about four weeks in immature teeth [59]. After these times,
the amount of each drug being released is lower than the
effective therapeutic levels. Hence, Ledermix paste used as an
intracanal medicament needs to be removed and replaced after
these time intervals in order to continue acting effectively.
In experimental studies, PDL healing was complete after
eight weeks following simulated avulsion injuries [61].
However, the healing response is also dependent on other
factors and therefore it may be delayed [61]. Factors that
delay healing include the presence of infection [61], physical
damage to the root and bone, contusion, rupture of blood
vessels, necrosis of damaged tissue, the presence of foreign
bodies [62] and the effects of concurrent distant wound
healing associated with other injuries [62,63]. Many or all of
these factors are likely to be present following trauma to teeth.
Hence, a cautious approach of allowing at least three months
for healing should be considered following most luxation
injuries. Ideally, the root canal system needs to be medicated
for at least this time and preferably for longer periods as the true
healing response is difficult to assess radiographically during
the first 3-6 months [40]. Ledermix paste is recommended
for the first three months – this implies two dressings of six
weeks each for mature teeth, or three dressings for four weeks
each in incompletely developed teeth. After three months,
a periapical radiograph should be taken to assess whether
there is any external inflammatory resorption occurring [40].
If resorption is evident, then continue using Ledermix paste
for a further three months to try and stop the resorption.
However, in almost all cases, there will be no inflammatory
resorption evident so calcium hydroxide can be introduced
into the medicament as a 50:50 mixture with Ledermix
 OHDM - Vol. 13 - No. 2 - June, 2014

Table 6. Recommended preventive treatment protocol for teeth with the injuries listed in Table 5 to prevent external inflammatory root resorption.
NOTES: 1) The treatment must be commenced as soon as the tooth has been replanted/repositioned and stabilised with splint;
2) Check the patient’s age, weight, allergies etc. to determine appropriate systemic antibiotic doses;
3) Alternative systemic antibiotics are penicillin and amoxicillin;
4) CS-AB = corticosteroid/antibiotic;
5) Working length and canal preparation can be deferred until the second treatment appointment.
Incompletely Developed Teeth
• Systemic antibiotics - start IMMEDIATELY
- Tetracycline preferred - e.g. doxycycline 100 mg - 2 tablets on the 1st day, and then 1 tablet daily for 1 week
• IMMEDIATELY after replantation/repositioning/splinting
- Remove the pulp, clean the root canal - if time: measure, file, irrigate, dry
- Place a CS-AB paste dressing - e.g. Ledermix paste
• After 4 weeks - complete canal preparation, place a new CS-AB paste dressing
• After another 4 weeks - place a new CS-AB paste dressing
• After another 4 weeks - take a periapical radiograph
- If no inflammatory resorption evident – place a dressing using a 50:50 mixture of CS-AB & Ca(OH)2
• After 2-3 months - take a periapical radiograph
- If no inflammatory resorption evident – place a Ca(OH)2 dressing – to induce formation of an apical hard tissue barrier
• Change the Ca(OH)2 dressing every 3 months until hard tissue repair (e.g. apexification) is evident. Periapical radiograph every 6 months to
ensure healing
• Place the root canal filling using gutta percha and cement
• Perform internal bleaching if required and then restore the access cavity
• Arrange to review after 6 months and then annually for at least 5 years
Fully Developed Teeth
• Systemic antibiotics - start IMMEDIATELY
- Tetracycline preferred - e.g. doxycycline 100 mg - 2 tablets on the 1st day, and then 1 tablet daily for 1 week
• IMMEDIATELY after replantation/repositioning/splinting
- Remove the pulp, clean the root canal - if time: measure, file, irrigate, dry
- Place a CS-AB paste dressing - e.g. Ledermix paste
• After 6 weeks - complete canal preparation, place a new CS-AB paste dressing
• After another 6 weeks - take a periapical radiograph
- If no inflammatory resorption evident – place a dressing using a 50:50 mixture of CS-AB & Ca(OH)2
• After 2-3 months - take a periapical radiograph
- If no inflammatory resorption evident – place the root canal filling using gutta percha and cement
• Perform internal bleaching if required and then restore the access cavity
• Arrange to review after 6 months and then annually for at least 5 years.

paste. The use of this combination reduces the toxicity of the
calcium hydroxide [64] and therefore there is less chance of
ankylosis and replacement resorption occurring. In addition,
this combination of materials increases the anti-bacterial
spectrum compared to Ledermix paste used alone [65,66],
and the hard tissue healing effects of the calcium hydroxide
can begin to work. There is a slight reduction in pH levels
of approximately 0.3 pH units when the medicaments are
combined [67] and each of the three main components of the
mixture (triamcinolone, demeclocycline, calcium hydroxide)
remain active [67]. The calcium hydroxide also has the
added effect of slowing down the release and diffusion of the
Ledermix paste components which means that they remain
in the canal for a longer period of time – up to three months
maximum [64]. Hence, a period of 2-3 months with the 50:50
mixture of Ledermix paste and calcium hydroxide can be
used to encourage further healing prior to completing the root
canal filling. If further hard tissue formation is required (e.g.
incompletely developed teeth requiring apexification), then
calcium hydroxide can be used alone after the 50:50 dressing
period. In these cases, the calcium hydroxide is ideally
replaced every three months until the tooth is ready for the
root canal filling (e.g. once an apical hard tissue barrier has
formed) [68]. The overall treatment time is about 12 months
on average for incompletely developed teeth when the extra
calcium hydroxide dressings are needed, and typically only
239
5-6 months for mature teeth. These time periods also allow
time to assess whether external replacement resorption and
ankylosis are occurring – if so, the overall prognosis of the
tooth needs to be determined and an alternative treatment plan
(such as extraction at an appropriate time) may be necessary.
The recommended approach for preventing external
inflammatory resorption is summarised in Table 6. This
approach may also help to reduce the amount of replacement
resorption to a small extent [45,51] but this type of resorption
is dependent on the amount and type of damage to the tooth
root and PDL during the actual injury as well as during the
repositioning or replantation procedures. This preventive
approach to avoid inflammatory resorption has been used
for many years by the authors. A review of 60 teeth in 52
patients managed by this approach showed that none of the
teeth developed external inflammatory root resorption [41]. In
these teeth, inflammatory resorption would have been highly
likely if no treatment had been provided due to the type of
injury sustained.
Strategy No. 5 - Follow-up of all traumatised teeth
It is essential to review and follow-up all traumatised teeth
in order to identify and manage any adverse consequences
as soon as they occur [12]. Most problems can be more
effectively managed if identified early – for example, if
external inflammatory resorption occurs in a tooth where
the above preventive approach has not been followed, there
 OHDM - Vol. 13 - No. 2 - June, 2014
will be less tooth structure loss if it is identified and managed
early rather than later. Treatment can be initiated to arrest
the resorption and then to encourage repair of the cementum,
PDL and bone [40,42]. This is more likely to be successful
if the resorption is not too advanced, whereas very advanced
cases are less likely to recover.
Some problems may be prevented through early
identification of symptoms or signs of unfavourable tissue
responses – for example, early identification and treatment
of pulp necrosis and infection of the root canal system will
minimise the loss of bone in the periapical region, reduce the
chances of other pathosis developing (such as extra-radicular
infections, periapical true cysts, etc) and generally have a
higher chance of healing of the periapical tissues.
There are some consequences of trauma to the teeth
that cannot be prevented or managed in a way that retains
the tooth in a stable, functional and aesthetic manner. For
example, external replacement resorption and ankylosis are
largely a result of damage to the tooth root and PDL during
the actual injury (i.e. avulsion, intrusion, lateral luxation, etc)
and sometimes during the replantation or repositioning of the
tooth, especially if performed by the patient, a bystander, or
other person with no dental training. In these cases, the damage
has been done before the patient sees the dentist. At this point
in time, research has not revealed any effective management
that will prevent or arrest external replacement resorption.
The studies mentioned above [45,51] have shown some slight
reduction in the amount of replacement resorption occurring in
teeth treated with corticosteroids and tetracycline antibiotics
(used both systemically and as intracanal medicaments) but
it is believed to be only a minimal and temporary effect.
Once external replacement resorption has commenced, it will
usually continue and result in loss of the tooth.
Some patients do not seek immediate or even early dental
treatment after having trauma to their teeth. In a study based
in a large Australian rural centre [4], approximately one third
of the patients presented to a dental clinic within 24 hours
of the injury, one third presented within one week and the
remaining third presented over periods ranging from one
week up to 52 weeks. Delays in seeking treatment mean
that the ideal treatment is not always possible to provide and
this can lead to the development of any of the unfavourable
tissue responses [69] outlined in Tables 1-3. Once most
problems have developed, they are usually more difficult to
References
1. Glendor U, Marcenes W, Andreasen JO. Classification:
epidemiology and etiology. In: Andreasen JO, Andreasen FM,
Andersson L (Editors) Textbook and color atlas of traumatic injuries
to the teeth. (4th Edn.) Oxford UK: Blackwell. 2007; pp. 217–254.
2. Andreasen JO, Ravn JJ. Epidemiology of traumatic dental
injuries to primary and permanent teeth in a Danish population
sample. International Journal of Oral Surgery. 1972; 1: 235-239.
3. Glendor U, Halling A, Andersson L, Eilert-Petersson E.
Incidence of traumatic tooth injuries in children and adolescents in
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4. Lam R, Abbott PV, Lloyd C, Lloyd C, Kruger E, et al. Dental
240
treat. Follow-up of patients who have delayed seeking initial
treatment is therefore even more essential than for those
patients who had ideal early or immediate management of
their injuries.
Regular follow-up of patients is important even when
there are obvious unfavourable responses that cannot be
managed conservatively since these will typically lead to
loss of the traumatised tooth or teeth. For example, external
replacement resorption and ankylosis, once present, will
progress to the point where the tooth will need to be extracted
and then replaced with some form of prosthesis since trauma
usually occurs to upper anterior teeth and most patients will
be concerned about the aesthetics following loss of the tooth.
A prosthesis will also be required for other reasons such as
function and arch stability. In these cases, the timing of the
extraction can be critical and will need considerable thought
and planning. Many factors will be involved and the ultimate
decision on when to extract may be determined by the type
of prosthesis chosen, patient age, patient activities (e.g. sport
participation, etc), amount of bone present, finances, etc. In
these cases it is critical that the rate of replacement resorption
is monitored by regular clinical reviews and radiographs to
determine when the tooth should be extracted.
Conclusions
There are many different potential responses of the pulp,
peri-radicular and soft tissues following trauma to a tooth.
The responses for each traumatised tooth are dependent on
many factors, including the type and extent of the injury,
the stage of root development and whether there has been
more than one injury to the same tooth. The responses of
the different tissues are inter-related and dependent on
each other. All of these factors imply that there are many
potential consequences of trauma to the teeth. It is imperative
that dentists have a thorough understanding of these tissue
responses so the appropriate treatment can be provided to
minimise the consequences of trauma to the teeth. The main
strategies to reduce the consequences include performing a
thorough examination and accurate diagnosis, repositioning
and stabilisation of the teeth and bones, careful soft tissue
management, immediate root canal treatment in specific
situations to prevent external inflammatory resorption, and
the follow-up of all traumatised teeth to identify and manage
any adverse consequences as soon as possible.
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